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A direct comparison of the American Psychiatric Association (APA), Finnish Medical Society Duodecim (FMSD), and National Collaborating Center for Mental Health/National Institute for Health and Clinical Excellence (NCCMH/NICE) recommendations for the management of eating disorders is provided in the tables below.
Some guidelines are broader in scope than others. For example, in addition to management, FMSD and NCCMH/NICE also address the screening for and identification of eating disorders. These topics, however, are beyond the scope of this synthesis. The APA guideline includes a discussion of clinical features influencing the treatment plan, including the chronicity of eating disorders, other psychiatric factors, concurrent general medical conditions, and demographic variables. These topics, however, are also beyond the scope of this synthesis.
While FMSD focuses on anorexia and bulimia nervosa, APA and NCCMH/NICE also address atypical eating disorders such as binge eating disorder and eating disorders not otherwise specified (EDNOS). The APA and NCCMH/NICE guidelines address areas where more research is needed. In formulating its conclusions, APA reviewed the NCCMH/NICE guideline and NCCMH/NICE reviewed the previous (2000) version of the APA guideline.
The tables below provide a side-by-side comparison of key attributes of each guideline, including specific interventions and practices that are addressed. The language used in these tables, particularly that which is used in Table 4, Table 5, and Table 6, is in most cases taken verbatim from the original guidelines:
A summary discussion of the areas of agreement and areas of differences among the guidelines is presented following the content comparison tables.
Abbreviations
TABLE 3: COMPARISON OF METHODOLOGY | |
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Methods Used to Collect/Select the Evidence | |
APA |
Described Process: A MEDLINE search, using PubMed, of "anorexia nervosa OR bulimia OR binge eating disorder OR binge eating disorders OR eating disorder OR eating disorders" yielded 15,561 citations, of which 3,596 were published between 1998 and 2004, were written in English, and contained abstracts. Of these, 334 were reports of clinical trials (including randomized controlled trials) or meta-analyses. Abstracts for these articles as well as abstracts for an additional 634 review articles were screened individually for their relevance to the guideline. The Cochrane Library was also searched for relevant abstracts. Additional, less formal literature searches were conducted by American Psychiatric Association (APA) staff and individual members of the Work Group on Eating Disorders. Number of Source Documents: Not stated Number of References: 765 |
FMSD |
Described Process: The evidence reviewed was collected from the Cochrane database of systematic reviews and the Database of Abstracts of Reviews of Effectiveness (DARE). In addition, the Cochrane Library and medical journals were searched specifically for original publications. Number of Source Documents: Not stated Number of References: 8 |
NCCMH/NICE |
Described Process: In conducting the review, the team systematically searched the literature for all English language systematic reviews relevant to the eating disorders scope that were published or updated after 1995. Search filters developed by the review team consisted of a combination of subject heading and free-text phrases. A general filter was developed for eating disorders along with more specific filters for each clinical question. In addition, filters were developed for randomized controlled trials (RCTs) and for other appropriate research designs. (The search filters can be found in Appendix 8 of the original document.) Electronic searches were made of the major bibliographic databases (MEDLINE, EMBASE, PsycINFO, CINAHL), in addition to the Cochrane Database of Systematic Reviews, the National Health Service Research and Development (NHS R&D) Health Technology Assessment database, Evidence-Based Mental Health and Clinical Evidence (Issue 5). Ineligible articles were excluded, and a second independent reviewer crosschecked these for relevance. The remaining references were acquired in full and re-evaluated for eligibility. The most recently published reviews that appropriately addressed a clinical question were selected. For each systematic review used, a search was made for new studies, and the papers for these and for existing studies were retrieved. The search for further evidence included research published after each review's search date, in-press papers identified by experts, and reviewing reference lists and recent contents of selected journals. All reports that were retrieved but later excluded are listed with reasons for exclusion in the appropriate evidence table. Where no relevant systematic reviews were located, the review team asked the Guideline Development Group (GDG) to decide whether a fresh systematic review should be undertaken. Eligible reviews were critically appraised for methodological quality and the reliability of this procedure was confirmed by parallel independent assessment. The eligibility/quality assessment was tested on a representative sample of papers. (Appendix 10 of the original document provides the quality checklist.) Cost Analysis Bibliographic electronic databases and health economic databases were searched for economic evidence using the combination of a specially developed health economics search filter and a general filter for eating disorders. A combination of subject headings and free text searches were used where possible. (The search strategies and the databases searched are presented in Appendix 12 of the full version of the original guideline document.) The search for further evidence included papers from reference lists of eligible studies and relevant reviews. Experts in the field of eating disorders and mental health economics were also contacted to identify additional relevant published and unpublished studies. Studies included in the clinical evidence review and stakeholders' submissions were also screened for economic evidence. Upon completion of the database searches, titles and abstracts of all references were screened for relevance to the scope of the guideline. The health economist then assessed relevant papers using a modified version of the Drummond et al. checklist (see Appendix 13 of the full version of the original guideline document). Number of Source Documents: Not stated Number of References: 408 |
Methods Used to Assess the Quality and Strength of the Evidence | |
APA |
Expert Consensus (Committee) |
FMSD |
Weighting According to a Rating Scheme (Scheme Given - Refer to Table 6) |
NCCMH/NICE |
Weighting According to a Rating Scheme (Scheme Given - Refer to Table 6) |
Methods Used to Analyze the Evidence | |
APA |
Described Process: The Work Group on Eating Disorders constructed evidence tables to illustrate the data regarding risks and benefits for each treatment and to evaluate the quality of the data. These tables facilitated group discussion of the evidence and agreement on treatment recommendations before guideline text was written. Evidence tables do not appear in the guideline; however, they are retained by APA to document the development process in case queries are received and to inform revisions of the guideline. |
FMSD |
Described Process: Not stated |
NCCMH/NICE |
Described Process: Synthesising the Evidence Where possible, outcome data were extracted directly from all eligible studies that met the quality criteria into Review Manager 4.2 (Cochrane Collaboration, 2003). Meta-analysis was then used to synthesise the evidence where appropriate using Review Manager. If necessary, reanalyses of the data or sensitivity analyses were used to answer clinical questions not addressed in the original studies or reviews. Where meta-analysis was not appropriate and/or possible, the reported results from each primary-level study were entered into the Access database. Evidence tables were used to summarise general information about each study. Consultation was used to overcome difficulties with coding. Data from studies included in existing systematic reviews were extracted independently by one reviewer directly into Review Manager and crosschecked with the existing data set. Two independent reviewers extracted data from new studies, and disagreements were resolved by discussion. Where consensus could not be reached, a third reviewer resolved the disagreement. Masked assessment (i.e., blind to the journal from which the article comes, the authors, the institution, and the magnitude of the effect) was not used since it is unclear that doing so reduces bias. Presenting the Data to the Guideline Development Group (GDG) Where possible, the GDG was given a graphical presentation of the results using forest plots generated with the Review Manager software. Each forest plot displayed the effect size and confidence interval (CI) for each study as well as the overall summary statistic. The graphs were organised so that the display of data in the area to the left of the "line of no effect" indicated a "favourable" outcome for the treatment in question. Dichotomous outcomes were presented as relative risks (RR) and the associated 95 percent CI. A relative risk (or risk ratio) is the ratio of the treatment event rate to the control event rate. A RR of 1 indicates no difference between treatment and control. All dichotomous outcomes were calculated on an intention-to-treat basis (i.e., a "once-randomised- always-analyse" basis). This assumes that those participants who ceased to engage in the study -- from whatever group -- had an unfavourable outcome (with the exception of the outcome of "death"). The Number Needed to Treat (NNT) or the Number Needed to Harm (NNH) was reported for each statistically significant outcome where the baseline risk (i.e., control group event rate) was similar across studies. In addition, NNTs calculated at follow-up were only reported where the length of follow-up was similar across studies. When length of follow-up or baseline risk varies (especially with low risk), the NNT is a poor summary of the treatment effect. Both the I2 test of heterogeneity and the chi-squared test of heterogeneity (p<0.10) were used, as well as visual inspection of the forest plots, to look for the possibility of heterogeneity. I2 describes the proportion of total variation in study estimates that is due to heterogeneity. An I2 of less than 30 percent was taken to indicate mild heterogeneity and a fixed effects model was used to synthesise the results. An I2 of more than 50 percent was taken as notable heterogeneity. In this case an attempt was made to explain the variation. If studies with heterogeneous results were found to be comparable, a random effects model was used to summarise the results. In the random effects analysis, heterogeneity is accounted for both in the width of CIs and in the estimate of the treatment effect. With decreasing heterogeneity the random effects approach moves asymptotically towards a fixed effects model. An I2 of 30 to 50 percent was taken to indicate moderate heterogeneity. In this case, both the chi-squared test of heterogeneity and a visual inspection of the forest plot were used to decide between a fixed and random effects model. To explore the possibility that the results entered into each meta-analysis suffered from publication bias, data from included studies were entered, where there was sufficient data, into a funnel plot. Asymmetry of the plot was taken to indicate possible publication bias and investigated further. |
Methods Used to Formulate the Recommendations | |
APA |
Expert Consensus (refer to Table 6 for rating scheme) Described Process: This practice guideline was developed under the auspices of the Steering Committee on Practice Guidelines. The development process is detailed in "APA Guideline Development Process," which is available from the APA Department of Quality Improvement and Psychiatric Services. The key features of this process include the following:
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FMSD |
Not stated |
NCCMH/NICE |
Described Process: The Guideline Development Group (GDG) The eating disorders GDG consisted of professionals in psychiatry, clinical psychology, nursing, social work, and general practice; academic experts in psychiatry and psychology; a patient, and a representative from a patient organisation. The carer perspective was provided through focus group discussion with carers; the group was run by the patient on the GDG. The guideline development process was supported by staff from the NCCMH review team, who undertook the clinical and health economics literature searches, reviewed and presented the evidence to the GDG, managed the process, and contributed to the drafting of the guideline. Guideline Development Group Meetings Twenty-three eating disorders GDG meetings were held between March 2002 and October 2003. During the series of day-long meetings, clinical questions were written, clinical evidence was reviewed and assessed, statements were developed, and recommendations were formulated. At each meeting, all GDG members declared any potential conflict of interests, and patient and carer concerns were routinely discussed as part of a standing agenda. Forming and Grading the Statements and Recommendations The evidence tables and forest plots formed the basis for developing clinical statements and recommendations. For intervention studies, the statements were classified according to an accepted hierarchy of evidence. Recommendations were then graded A to C based on the level of associated evidence (see Table 6). In order to facilitate consistency in generating and drafting the clinical statements the GDG utilised a statement decision tree. The flowchart was designed to assist with, but not replace, clinical judgement. Where a statistically significant summary statistic (effect size [ES]) was obtained (after controlling for heterogeneity), the GDG considered whether this finding was of clinical significance (i.e., likely to be of benefit to patients) taking into account the trial population, nature of the outcome, and size of the effect. On the basis of this consideration the ES was characterised as "clinically significant" or not. A further consideration was made about the strength of the evidence by examining the confidence interval (CI) surrounding the ES. For level I evidence, where the ES was judged to be clinically significant and had a CI entirely within a clinical relevant range, the result was characterised as "strong evidence" (S1). For non-level I evidence or in situations where the upper/lower bound of the CI was not clinically significant, the result was characterised as "limited evidence" (S2). Where an ES was statistically significant, but not clinically significant and the CI excluded values judged to be clinically important, the result was characterised as "unlikely to be clinically significant" (S3). Alternatively, if the CI included clinically important values, the result was characterised as "insufficient to determine clinical significance" (S6). Where a non-statistically significant ES was obtained, the GDG reviewed the trial population, nature of the outcome, size of the effect and, in particular, the CI surrounding the result. If the CI was narrow and excluded a clinically significant ES, this was seen as indicating evidence of "no clinically significant difference" (S4), but where the CI was wide this was seen as indicating 'insufficient evidence' to determine if there was a clinically significant difference or not (S5). Once all evidence statements relating to a particular clinical question were finalised and agreed by the GDG, the associated recommendations were produced and graded. Grading the recommendations allowed the GDG to distinguish between the level of evidence and the strength of the associated recommendation. It is possible that a statement of evidence would cover only one part of an area in which a recommendation was to be made or would cover it in a way that would conflict with other evidence. In order to produce more comprehensive recommendations suitable for people in England and Wales, the GDG had to extrapolate from the available evidence. This led to a weaker level of recommendation (i.e., B, as data were based upon level I evidence). It is important to note that the grading of the recommendation is not a reflection of its clinical significance or relevance. A number of issues relating to the study of eating disorders meant that the outcomes available for analysis were classified as primary or secondary. When making recommendations, the primary outcomes were given more weight during the decision process. The process also allowed the GDG to moderate recommendations based on factors other than the strength of evidence. Such considerations include the applicability of the evidence to people with eating disorders, economic considerations, values of the development group and society, or the group's awareness of practical issues. Method Used to Answer a Clinical Question in the Absence of Appropriately Designed, High-Quality Research Where it was not possible to identify at least one appropriately designed study or high-quality systematic review, or where the GDG was of the opinion (on the basis of previous searches or their knowledge of the literature) that there was unlikely to be appropriately designed primary-level research that directly addressed the clinical question, an informal consensus process was adopted. This process focused on those questions that the GDG considered a priority. The starting point for this process of informal consensus was that a member of the topic group identified, with help from the systematic reviewer, a narrative review that most directly addressed the clinical question. Where this was not possible a new review of the recent literature was initiated. This existing narrative review or new review was used as a basis for identifying lower levels of evidence relevant to the clinical question. This was then presented for discussion to the GDG. On the basis of this, additional information was sought and added to the information collected. This may include studies that did not directly address the clinical question but were thought to contain relevant data. This led to the development of an initial draft report that addressed the following issues:
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Outcomes | |
APA |
Anorexia Nervosa
Bulimia Nervosa
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FMSD |
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NCCMH/NICE |
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Financial Disclosures/Conflicts of Interest | |
APA |
This practice guideline has been developed by psychiatrists who are in active clinical practice. In addition, some contributors are primarily involved in research or other academic endeavors. It is possible that through such activities some contributors, including work group members and reviewers, have received income related to treatments discussed in this guideline. A number of mechanisms are in place to minimize the potential for producing biased recommendations due to conflicts of interest. Work group members are selected on the basis of their expertise and integrity. Any work group member or reviewer who has a potential conflict of interest that may bias (or appear to bias) his or her work is asked to disclose this to the Steering Committee on Practice Guidelines and the work group. Iterative guideline drafts are reviewed by the Steering Committee, other experts, allied organizations, APA members, and the APA Assembly and Board of Trustees; substantial revisions address or integrate the comments of these multiple reviewers. The development of the APA practice guidelines is not financially supported by any commercial organization. |
FMSD |
Not stated |
NCCMH/NICE |
All Guideline Development Group (GDG) members made formal declarations of interest at the outset, which were updated at every GDG meeting. |
TABLE 4: COMPARISON OF RECOMMENDATIONS FOR THE MANAGEMENT/TREATMENT OF EATING DISORDERS | |
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Comprehensive Assessment and Coordination of Care | |
APA |
Psychiatric Management
Coordinating Care and Collaborating with Other Clinicians In treating adults with eating disorders, the psychiatrist may assume the leadership role within a program or team that includes other physicians, psychologists, registered dietitians, and social workers or may work collaboratively on a team led by others.
Assessing and Monitoring Eating Disorder Symptoms and Behaviors
Assessing and Monitoring the Patient's General Medical Condition
Assessing and Monitoring the Patient's Safety and Psychiatric Status
Providing Family Assessment and Treatment
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FMSD |
Treatment
|
NCCMH/NICE |
Care Across All Conditions Assessment and Coordination of Care C - Assessment of people with eating disorders should be comprehensive and include physical, psychological, and social needs and a comprehensive assessment of risk to self. C - The level of risk to the patient's mental and physical health should be monitored as treatment progresses because it may change--for example, following weight gain or at times of transition between services in cases of anorexia nervosa. C - For people with eating disorders presenting in primary care, general practitioners (GPs) should take responsibility for the initial assessment and the initial coordination of care. This includes the determination of the need for emergency medical or psychiatric assessment. C - Where management is shared between primary and secondary care, there should be clear agreement among individual health care professionals on the responsibility for monitoring patients with eating disorders. This agreement should be in writing (where appropriate using the care programme approach) and should be shared with the patient and, where appropriate, his or her family and carers. Providing Good Information and Support C - Health care professionals should acknowledge that many people with eating disorders are ambivalent about treatment. Health care professionals should also recognise the consequent demands and challenges this presents. Getting Help Early C - People with eating disorders seeking help should be assessed and receive treatment at the earliest opportunity. C - Whenever possible patients should be engaged and treated before reaching severe emaciation. This requires both early identification and intervention. Effective monitoring and engagement of patients at severely low weight or with falling weight should be a priority. Additional Considerations for Children and Adolescents C - Family members, including siblings, should normally be included in the treatment of children and adolescents with eating disorders. Interventions may include sharing of information, advice on behavioural management, and facilitating communication. C - In children and adolescents with eating disorders, growth and development should be closely monitored. Where development is delayed or growth is stunted despite adequate nutrition, paediatric advice should be sought. C - Health care professionals assessing children and adolescents with eating disorders should be alert to indicators of abuse (emotional, physical and sexual) and should remain so throughout treatment. C - The right to confidentiality of children and adolescents with eating disorders should be respected. C - Health care professionals working with children and adolescents with eating disorders should familiarise themselves with national guidelines and their employers' policies in the area of confidentiality. Anorexia Nervosa Assessment and Management of Anorexia Nervosa in Primary Care C - In anorexia nervosa, although weight and BMI are important indicators of physical risk they should not be considered the sole indicators (as they are unreliable in adults and especially in children). C - Patients with enduring anorexia nervosa not under the care of a secondary care service should be offered an annual physical and mental health review by their GP. Identification of Eating Disorders in Primary Care Screening Initial Physical Assessment The rationale for physical assessment is more to determine the presence and severity of emaciation and secondary physical consequences of the anorexia nervosa than to ascertain the primary diagnosis. It should include as a minimum:
The following may also be helpful to assess the risk of physical instability:
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Determination of Treatment Setting | |
APA |
Psychiatric Management Choosing a Treatment Site Services available for treating eating disorders can range from intensive inpatient programs (in which general medical care is readily available) to residential and partial hospitalization programs to varying levels of outpatient care (in which the patient receives general medical treatment, nutritional counseling, and/or individual, group, and family psychotherapy). Because specialized programs are not available in all geographic areas and their financial requirements are often significant, access to these programs may be limited; petition, explanation, and follow-up by the psychiatrist on behalf of patients and families may help procure access to these programs.
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FMSD |
Treatment
Related Resources
|
NCCMH/NICE |
Service Interventions for Anorexia Nervosa This section considers those aspects of the service system relevant to the treatment and management of anorexia nervosa. C - Most people with anorexia nervosa should be treated on an outpatient basis. C - Where inpatient management is required, this should be provided within reasonable travelling distance to enable the involvement of relatives and carers in treatment, to maintain social and occupational links, and to avoid difficulty in transition between primary and secondary care services. This is particularly important in the treatment of children and adolescents. C - Inpatient treatment should be considered for people with anorexia nervosa whose disorder is associated with high or moderate physical risk. C - People with anorexia nervosa requiring inpatient treatment should be admitted to a setting that can provide the skilled implementation of refeeding with careful physical monitoring (particularly in the first few days of refeeding), in combination with psychosocial interventions. C - Inpatient treatment or day patient treatment should be considered for people with anorexia nervosa whose disorder has not improved with appropriate outpatient treatment, or for whom there is a significant risk of suicide or severe self-harm. C - Health care professionals without specialist experience of eating disorders, or in situations of uncertainty, should consider seeking advice from an appropriate specialist when contemplating a compulsory admission for a patient with anorexia nervosa, regardless of the age of the patient. C - Health care professionals managing patients with anorexia nervosa, especially that of the binge purging sub-type, should be aware of the increased risk of self-harm and suicide, particularly at times of transition between services or service settings. Additional Considerations for Children and Adolescents C - Admission of children and adolescents with anorexia nervosa should be to age-appropriate facilities (with the potential for separate children and adolescent services), which have the capacity to provide appropriate educational and related activities. C - When a young person with anorexia nervosa refuses treatment that is deemed essential, consideration should be given to the use of the Mental Health Act 1983 or the right of those with parental responsibility to override the young person's refusal. C - Relying indefinitely on parental consent to treatment should be avoided. It is recommended that the legal basis under which treatment is being carried out should be recorded in the patient's case notes, and this is particularly important in the case of children and adolescents. C - For children and adolescents with anorexia nervosa, where issues of consent to treatment are highlighted, health care professionals should consider seeking a second opinion from an eating disorders specialist. C - If the patient with anorexia nervosa and those with parental responsibility refuse treatment, and treatment is deemed to be essential, legal advice should be sought in order to consider proceedings under the Children Act 1989. Service Interventions for Bulimia Nervosa The great majority of patients with bulimia nervosa can be treated as outpatients. There is a very limited role for the inpatient treatment of bulimia nervosa. This is primarily concerned with the management of suicide risk or severe self-harm. C - The great majority of patients with bulimia nervosa should be treated in an outpatient setting. C - For patients with bulimia nervosa who are at risk of suicide or severe self-harm, admission as an inpatient or day patient, or the provision of more intensive outpatient care, should be considered. C - Psychiatric admission for people with bulimia nervosa should normally be undertaken in a setting with experience of managing this disorder. C - Health care professionals should be aware that patients with bulimia nervosa who have poor impulse control, notably substance misuse, may be less likely to respond to a standard programme of treatment. As a consequence treatment should be adapted to the problems presented. |
Physical Management/Nutritional Rehabilitation | |
APA |
Choice of Specific Treatments for Anorexia Nervosa The aims of treating anorexia nervosa are to 1) restore patients to a healthy weight (associated with the return of menses and normal ovulation in female patients, normal sexual drive and hormone levels in male patients, and normal physical and sexual growth and development in children and adolescents); 2) treat physical complications; 3) enhance patients' motivation to cooperate in the restoration of healthy eating patterns and participate in treatment; 4) provide education regarding healthy nutrition and eating patterns; 5) help patients reassess and change core dysfunctional cognitions, attitudes, motives, conflicts, and feelings related to the eating disorder; 6) treat associated psychiatric conditions, including deficits in mood and impulse regulation and self-esteem and behavioral problems; 7) enlist family support and provide family counseling and therapy where appropriate; and 8) prevent relapse. Nutritional Rehabilitation
Choice of Specific Treatments for Bulimia Nervosa The aims of treatment for patients with bulimia nervosa are to 1) reduce and, where possible, eliminate binge eating and purging; 2) treat physical complications of bulimia nervosa; 3) enhance patients' motivation to cooperate in the restoration of healthy eating patterns and participate in treatment; 4) provide education regarding healthy nutrition and eating patterns; 5) help patients reassess and change core dysfunctional thoughts, attitudes, motives, conflicts, and feelings related to the eating disorder; 6) treat associated psychiatric conditions, including deficits in mood and impulse regulation, self-esteem, and behavior; 7) enlist family support and provide family counseling and therapy where appropriate; and 8) prevent relapse. Nutritional Rehabilitation Counseling
Eating Disorder Not Otherwise Specified
Binge Eating Disorder Nutritional Rehabilitation and Counseling
|
FMSD |
No specific recommendations offered. The treatment is divided into:
|
NCCMH/NICE |
Care Across All Conditions Management of Physical Aspects C - Where laxative abuse is present, patients should be advised to gradually reduce laxative use and informed that laxative use does not significantly reduce calorie absorption. C - Treatment of both subthreshold and clinical cases of an eating disorder in people with diabetes is essential because of the greatly increased physical risk in this group. C - People with type 1 diabetes and an eating disorder should have intensive regular physical monitoring because they are at high risk of retinopathy and other complications. C - Pregnant women with eating disorders require careful monitoring throughout the pregnancy and in the postpartum period. C - Patients with an eating disorder who are vomiting should have regular dental reviews. C - Patients who are vomiting should be given appropriate advice on dental hygiene, which should include avoiding brushing after vomiting; rinsing with a non-acid mouthwash after vomiting; and reducing an acid oral environment (for example, limiting acidic foods). C - Health care professionals should advise people with eating disorders and osteoporosis or related bone disorders to refrain from physical activities that significantly increase the likelihood of falls. Additional Considerations for Children and Adolescents C - In children and adolescents with eating disorders, growth and development should be closely monitored. Where development is delayed or growth is stunted despite adequate nutrition, paediatric advice should be sought. Anorexia Nervosa Physical Management of Anorexia Nervosa Anorexia nervosa carries considerable risk of serious physical morbidity. Awareness of the risk, careful monitoring, and, where appropriate, close liaison with an experienced physician are important in the management of the physical complications of anorexia nervosa. Managing Weight Gain C - In most patients with anorexia nervosa, an average weekly weight gain of 0.5 to 1 kg in inpatient settings and 0.5 kg in outpatient settings should be an aim of treatment. This requires about 3,500 to 7,000 extra calories a week. C - Regular physical monitoring, and in some cases treatment with a multi-vitamin/multi-mineral supplement in oral form, is recommended for people with anorexia nervosa during both inpatient and outpatient weight restoration. C - Total parenteral nutrition should not be used for people with anorexia nervosa, unless there is significant gastrointestinal dysfunction. Managing Risk C - Health care professionals should monitor physical risk in patients with anorexia nervosa. If this leads to the identification of increased physical risk, the frequency of the monitoring and nature of the investigations should be adjusted accordingly. C - People with anorexia nervosa and their carers should be informed if the risk to their physical health is high. C - The involvement of a physician or paediatrician with expertise in the treatment of physically at-risk patients with anorexia nervosa should be considered for all individuals who are physically at risk. C - Pregnant women with either current or remitted anorexia nervosa may need more intensive prenatal care to ensure adequate prenatal nutrition and fetal development. C - Oestrogen administration should not be used to treat bone density problems in children and adolescents as this may lead to premature fusion of the epiphyses. Feeding Against the Will of the Patient C - Feeding against the will of the patient should be an intervention of last resort in the care and management of anorexia nervosa. C - Feeding against the will of the patient is a highly specialized procedure requiring expertise in the care and management of those with severe eating disorders and the physical complications associated with it. This should only be done in the context of the Mental Health Act 1983 or Children Act 1989. C - When making the decision to feed against the will of the patient, the legal basis for any such action must be clear. Additional Considerations for Children and Adolescents C - Health care professionals should ensure that children and adolescents with anorexia nervosa who have reached a healthy weight have the increased energy and necessary nutrients available in their diet to support further growth and development. C - In the nutritional management of children and adolescents with anorexia nervosa, carers should be included in any dietary education or meal planning. Other Physical Interventions Physical monitoring is necessary during periods of refeeding. A range of electrolyte disturbances can occur during refeeding, which are sometimes referred to collectively as the "refeeding syndrome." Hypophosphataemia may develop rapidly during refeeding; if severe, it can cause cardiac and respiratory failure, delirium, and fits. Ingestion of large quantities of carbohydrates, during rapid refeeding, may result in a precipitate drop in serum phosphate levels. Therefore, in the first few days of refeeding patients who have had very low or absent intakes for long periods, no attempt should be made to achieve net weight gain. Instead they should receive energy and protein provision at levels at or less than their estimated basal requirements with generous provision of balanced multi-vitamins and minerals especially thiamine, potassium, magnesium, and phosphate. Bulimia Nervosa Management of Physical Aspects of Bulimia Nervosa Patients with bulimia nervosa can experience considerable physical problems as a result of a range of behaviours associated with the condition. Awareness of the risks and careful monitoring should be a concern of all health care professionals working with people with this disorder. C - Patients with bulimia nervosa who are vomiting frequently or taking large quantities of laxatives (especially if they are also underweight) should have their fluid and electrolyte balance assessed. C - When electrolyte disturbance is detected, it is usually sufficient to focus on eliminating the behaviour responsible. In the small proportion of cases where supplementation is required to restore electrolyte balance, oral rather than intravenous administration is recommended, unless there are problems with gastrointestinal absorption. |
Psychological Interventions | |
APA |
Choice of Specific Treatments for Anorexia Nervosa Psychosocial Interventions The goals of psychosocial interventions are to help patients with anorexia nervosa 1) understand and cooperate with their nutritional and physical rehabilitation, 2) understand and change the behaviors and dysfunctional attitudes related to their eating disorder, 3) improve their interpersonal and social functioning, and 4) address comorbid psychopathology and psychological conflicts that reinforce or maintain eating disorder behaviors. Acute Anorexia Nervosa
Anorexia Nervosa after Weight Restoration Once malnutrition has been corrected and weight gain has begun, psychotherapy can help patients with anorexia nervosa understand 1) their experience of their illness; 2) cognitive distortions and how these have led to their symptomatic behavior; 3) developmental, familial, and cultural antecedents of their illness; 4) how their illness may have been a maladaptive attempt to regulate their emotions and cope; 5) how to avoid or minimize the risk of relapse; and 6) how to better cope with salient developmental and other important life issues in the future.
Although families and patients are increasingly accessing worthwhile, helpful information through online web sites, newsgroups, and chat rooms, the lack of professional supervision within these resources may sometimes lead to users' receiving misinformation or create unhealthy dynamics among users.
Chronic Anorexia Nervosa Patients with chronic anorexia nervosa generally show a lack of substantial clinical response to formal psychotherapy.
Choice of Specific Treatments for Bulimia Nervosa Psychosocial Interventions
Eating Disorder Not Otherwise Specified
Binge Eating Disorder Nutritional Rehabilitation and Counseling
Other Psychosocial Treatments
Combining Psychosocial and Medication Treatments
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FMSD |
Treatment
Related Resources
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NCCMH/NICE |
Psychological Interventions for Anorexia Nervosa The delivery of psychological interventions should be accompanied by regular monitoring of a patient's physical state including weight and specific indicators of increased physical risk. Common Elements of the Psychological Treatment of Anorexia Nervosa C - Therapies to be considered for the psychological treatment of anorexia nervosa include CAT, CBT, IPT, focal psychodynamic therapy, and family interventions focused explicitly on eating disorders. C - Patient and, where appropriate, carer preference should be taken into account in deciding which psychological treatment is to be offered. C - The aims of psychological treatment should be to reduce risk, to encourage weight gain and healthy eating, to reduce other symptoms related to an eating disorder, and to facilitate psychological and physical recovery. Outpatient Psychological Treatments in First Episode and Later Episodes C - Most people with anorexia nervosa should be managed on an outpatient basis, with psychological treatment (with physical monitoring) provided by a health care professional competent to give it and to assess the physical risk of people with eating disorders. C - Outpatient psychological treatment and physical monitoring for anorexia nervosa should normally be of at least 6 months' duration. C - For patients with anorexia nervosa, if during outpatient psychological treatment there is significant deterioration, or the completion of an adequate course of outpatient psychological treatment does not lead to any significant improvement, more intensive forms of treatment (for example, a move from individual therapy to combined individual and family work or day care or inpatient care) should be considered. C - Dietary counselling should not be provided as the sole treatment for anorexia nervosa. Psychological Aspects of Inpatient Care C - For inpatients with anorexia nervosa, a structured symptom-focused treatment regimen with the expectation of weight gain should be provided in order to achieve weight restoration. It is important to carefully monitor the patient's physical status during refeeding. C - Psychological treatment should be provided which has a focus both on eating behaviour and attitudes to weight and shape and on wider psychosocial issues with the expectation of weight gain. C - Rigid inpatient behaviour modification programmes should not be used in the management of anorexia nervosa. Post-Hospitalisation Psychological Treatment C - Following inpatient weight restoration, people with anorexia nervosa should be offered outpatient psychological treatment that focuses both on eating behaviour and attitudes to weight and shape and on wider psychosocial issues, with regular monitoring of both physical and psychological risk. C - The length of outpatient psychological treatment and physical monitoring following inpatient weight restoration should typically be at least 12 months. Additional Considerations for Children and Adolescents with Anorexia Nervosa B - Family interventions that directly address the eating disorder should be offered to children and adolescents with anorexia nervosa. C - Children and adolescents with anorexia nervosa should be offered individual appointments with a health care professional separate from those with their family members or carers. C - The therapeutic involvement of siblings and other family members should be considered in all cases because of the effects of anorexia nervosa on other family members. C - In children and adolescents with anorexia nervosa, the need for inpatient treatment and the need for urgent weight restoration should be balanced alongside the educational and social needs of the young person. Bulimia Nervosa Psychological Interventions for Bulimia Nervosa B - As a possible first step, patients with bulimia nervosa should be encouraged to follow an evidence-based self-help programme. B - Health care professionals should consider providing direct encouragement and support to patients undertaking an evidence-based self-help programme, as this may improve outcomes. This may be sufficient treatment for a limited subset of patients. A - CBT-BN, a specifically adapted form of CBT, should be offered to adults with bulimia nervosa. The course of treatment should be for 16 to 20 sessions over 4 to 5 months. B - When people with bulimia nervosa have not responded to or do not want CBT, other psychological treatments should be considered. B - Interpersonal psychotherapy should be considered as an alternative to CBT, but patients should be informed it takes 8-12 months to achieve results comparable with CBT. Additional Considerations for Children and Adolescents C - Adolescents with bulimia nervosa may be treated with CBT-BN adapted as needed to suit their age, circumstances, and level of development, and including the family as appropriate. Atypical Eating Disorders Including Binge Eating Disorder General Treatment of Atypical Eating Disorders C - In the absence of evidence to guide the management of atypical eating disorders (eating disorders not otherwise specified) other than binge eating disorder, it is recommended that the clinician considers following the guidance on the treatment of the eating problem that most closely resembles the individual patient's eating disorder. Psychological Treatments for Binge Eating Disorder B - As a possible first step, patients with binge eating disorder should be encouraged to follow an evidence-based self-help programme. B - Health care professionals should consider providing direct encouragement and support to patients undertaking an evidence-based self-help programme as this may improve outcomes. This may be sufficient treatment for a limited subset of patients. A - CBT-BED, a specifically adapted form of CBT, should be offered to adults with binge eating disorder. B - Other psychological treatments (interpersonal psychotherapy for binge eating disorder and modified dialectical behaviour therapy) may be offered to adults with persistent binge eating disorder. A - Patients should be informed that all psychological treatments for binge eating disorder have a limited effect on body weight. C - When providing psychological treatments for patients with binge eating disorder, consideration should be given to the provision of concurrent or consecutive interventions focusing on the management of comorbid obesity. C - Suitably adapted psychological treatments should be offered to adolescents with persistent binge eating disorder. |
Pharmacological Interventions | |
APA |
Choice of Specific Treatments for Anorexia Nervosa Medications and Other Somatic Treatments Weight Restoration
Relapse Prevention
Chronic Anorexia Nervosa
Choice of Specific Treatments for Bulimia Nervosa Medications Initial Treatment
Maintenance Phase
Combining Psychosocial Interventions and Medications
Other Treatments
Eating Disorder Not Otherwise Specified Binge Eating Disorder Medications
Combining Psychosocial and Medication Treatments
Night Eating Syndrome
|
FMSD |
Medical Treatment
Related Evidence
|
NCCMH/NICE |
Anorexia Nervosa Pharmacological Interventions for Anorexia Nervosa There is a very limited evidence base for the pharmacological treatment of anorexia nervosa. A range of drugs may be used in the treatment of comorbid conditions but caution should be exercised in their use given the physical vulnerability of many people with anorexia nervosa. C - Medication should not be used as the sole or primary treatment for anorexia nervosa. C - Caution should be exercised in the use of medication for comorbid conditions such as depressive or obsessive-compulsive features, as they may resolve with weight gain alone. C - When medication is used to treat people with anorexia nervosa, the side effects of drug treatment (in particular, cardiac side effects) should be carefully considered because of the compromised cardiovascular function of many people with anorexia nervosa. C - Health care professionals should be aware of the risk of drugs that prolong the QTc interval on the ECG (for example, antipsychotics, tricyclic antidepressants, macrolide antibiotics, and some antihistamines). In patients with anorexia nervosa at risk of cardiac complications, the prescription of drugs with side effects that may compromise cardiac functioning should be avoided. C - If the prescription of medication that may compromise cardiac functioning is essential, ECG monitoring should be undertaken. C - All patients with a diagnosis of anorexia nervosa should have an alert placed in their prescribing record concerning the risk of side effects. Bulimia Nervosa Pharmacological Interventions for Bulimia Nervosa B - As an alternative or additional first step to using an evidence-based self-help programme, adults with bulimia nervosa may be offered a trial of an antidepressant drug. B - Patients should be informed that antidepressant drugs can reduce the frequency of binge eating and purging, but the long-term effects are unknown. Any beneficial effects will be rapidly apparent. C - SSRIs (specifically fluoxetine) are the drugs of first choice for the treatment of bulimia nervosa in terms of acceptability, tolerability, and reduction of symptoms. C - For people with bulimia nervosa, the effective dose of fluoxetine is higher than for depression (60 mg daily). B - No drugs, other than antidepressants, are recommended for the treatment of bulimia nervosa. Atypical Eating Disorders Including Binge Eating Disorder General Treatment of Atypical Eating Disorders C - In the absence of evidence to guide the management of atypical eating disorders (eating disorders not otherwise specified) other than binge eating disorder, it is recommended that the clinician considers following the guidance on the treatment of the eating problem that most closely resembles the individual patient's eating disorder. Pharmacological Interventions for Binge Eating Disorder B - As an alternative or additional first step to using an evidence based self-help programme, consideration should be given to offering a trial of an SSRI antidepressant drug to patients with binge eating disorder. B - Patients with binge eating disorders should be informed that SSRIs can reduce binge eating, but the long-term effects are unknown. Antidepressant drug treatment may be sufficient treatment for a limited subset of patients. |
Education | |
APA |
Basic psychiatric management includes support through the provision of educational materials, including self-help workbooks; information on community-based and Internet resources; and direct advice to patients and their families (if they are involved) [I]. |
FMSD |
No recommendations offered. |
NCCMH/NICE |
Providing Good Information and Support C - Patients and, where appropriate, carers should be provided with education and information on the nature, course and treatment of eating disorders. C - In addition to the provision of information, family and carers may be informed of self-help groups and support groups and offered the opportunity to participate in such groups where they exist. Management of Physical Aspects C - Patients who are vomiting should be given appropriate advice on dental hygiene, which should include avoiding brushing after vomiting; rinsing with a non-acid mouthwash after vomiting; and reducing an acid oral environment (for example, limiting acidic foods). |
TABLE 5: BENEFITS AND HARMS | |
---|---|
Benefits | |
APA (2006) |
Appropriate treatment of eating disorders with improved clinical outcomes |
FMSD (2007) |
Appropriate diagnosis and treatment of eating disorders among children and adolescents |
NCCMH/NICE (2004) |
Consistent quality of care for patients with eating disorders including anorexia nervosa, bulimia nervosa, and related eating disorders |
Harms | |
APA (2006) |
Treatment of Anorexia Nervosa
Treatment of Bulimia Nervosa
|
FMSD (2007) |
Adverse effects associated with antidepressants |
NCCMH/NICE (2004) |
|
TABLE 6: EVIDENCE RATING SCHEMES | |
---|---|
APA (2006) |
Each recommendation is identified at falling into one of three categories of endorsement, indicated by a bracketed Roman numeral following the statement. The three categories represent varying levels of clinical confidence regarding the recommendation: [I] Recommended with substantial clinical confidence. [II] Recommended with moderate clinical confidence. [III] May be recommended on the basis of individual circumstances. |
FMSD (2007) |
Classification of the Quality of Evidence
|
NCCMH/NICE (2004) |
RATING SCHEME FOR THE STRENGTH OF THE EVIDENCE Levels of Evidence I: Evidence obtained from a single randomised controlled trial or a meta-analysis of randomised controlled trials IIa: Evidence obtained from at least one well-designed controlled study without randomisation IIb: Evidence obtained from at least one well-designed quasi-experimental study III: Evidence obtained from well-designed non-experimental descriptive studies, such as comparative studies, correlation studies and case-control studies IV: Evidence obtained from expert committee reports or opinions and/or clinical experience of respected authorities Strength of Recommendations Grade A - At least one randomised controlled trial as part of a body of literature of overall good quality and consistency addressing the specific recommendation (evidence level I) without extrapolation Grade B - Well-conducted clinical studies but no randomised clinical trials on the topic of recommendation (evidence levels II or III); or extrapolated from level I evidence Grade C - Expert committee reports or opinions and/or clinical experiences of respected authorities (evidence level IV) or extrapolated from level I or II evidence. This grading indicates that directly applicable clinical studies of good quality are absent or not readily available. |
The American Psychiatric Association (APA), Finnish Medical Society Duodecim (FMSD), and National Collaborating Centre for Mental Health/National Institute for Health and Clinical Excellence (NCCMH/NICE) present recommendations for the management of eating disorders.
Some guidelines are broader in scope than others. For example, in addition to management, FMSD and NCCMH/NICE also address the screening for and identification of eating disorders. These topics, however, are beyond the scope of this synthesis. APA addresses a North American population, while FMSD and NCCMH/NICE address a European population (Finland and the United Kingdom, respectively).
While FMSD focuses on anorexia and bulimia nervosa, APA and NCCMH/NICE also address atypical eating disorders such as binge eating disorder and eating disorders not otherwise specified (EDNOS). The APA and NCCMH/NICE guidelines address areas where more research is needed.
In formulating its conclusions, APA reviewed the NCCMH/NICE guideline and NCCMH/NICE reviewed the previous (2000) version of the APA guideline.
Regarding the methods used to collect and select the evidence, all three groups performed searches of electronic databases, with FMSD and NCCMH/NICE also performing hand-searches of published literature (both primary and secondary sources). All of the groups describe relevant information about the electronic databases searched, with APA and NCCMH/NICE also providing the specific search terms used and the time range over which data were obtained.
To assess the quality and strength of the evidence, both FMSD and NCCMH/NICE weigh the evidence according to a rating scheme, while APA uses expert consensus.
All three groups performed a review of published meta-analyses to analyze the evidence, along with a systematic review (FMSD) or systematic review with evidence tables (APA, NCCMH/NICE). APA and NCCMH/NICE describe the processes used.
Both APA and NCCMH/NICE employed expert consensus to formulate their recommendations, and both use a grading scheme to indicate the strength of each individual recommendation. FMSD does not provide the methods used to formulate the recommendations.
All groups provided reference lists. APA and NCCMH/NICE stated that work group members were required to provide formal declarations of interest at the outset of the development process, while FMSD did not disclose potential conflicts of interest.
There is general agreement among the guidelines that a comprehensive initial assessment of patients diagnosed with an eating disorder should be performed and should include an evaluation of physical condition, mental status (including risk to self), and eating disorder attitudes and behaviors.
In terms of coordination of care, there is overall agreement that patients should be managed in a multidisciplinary team fashion, with all involved caregivers (physicians, psychologists, registered dietitians, social workers, physician specialists, dentists, etc.) collaborating to promote the well-being of the patient. Each team member's role should be clearly identified, and open communication between all parties should be encouraged.
There is general agreement that important factors to consider in determining the most appropriate treatment setting include the overall physical condition, psychology, behaviors, and social circumstances of the patient. APA and NCCMH/NICE are in agreement that most patients with uncomplicated bulimia nervosa can be treated as outpatients, but that patients at risk of suicide or severe self-harm or with other risk factors may warrant hospitalization.
The two guidelines that address nutritional rehabilitation (APA and NCCMH/NICE) are in agreement that weight gain regimens are a key component of the treatment of anorexia nervosa. APA recommends a target weight gain of 2 to 3 lbs/week for hospitalized patients and 0.5 to 1 lb/week for outpatients, with a caloric intake beginning at approximately 1,000 to 1,600 kcal/day and increasing to 70 to 100 kcal/kg per day for certain patients. NCCMH/NICE notes that 0.5 to 1 kg (1.1 to 2.2 lbs) in inpatient settings and 0.5 kg (1.1 lbs) in outpatient settings should be aims of treatment, which requires about 3,500 to 7,000 extra calories a week.
APA and NCCMH/NICE acknowledge that providing nutrition parentally or via a nasogastric tube may be required in inpatient settings. NCCMH/NICE states that total parenteral nutrition should not be used for people with anorexia nervosa in the absence of significant gastrointestinal dysfunction. APA states that nasogastric feeding is preferable to intravenous feeding.
APA and NCCMH/NICE are in agreement that refeeding syndrome is a serious concern associated with administration of life-preserving nutrition, and that appropriate monitoring for the associated possible cardiovascular, neurologic, and hematologic complications is necessary. The guidelines agree that slow refeeding, with supplementation of vitamins and minerals as indicated, is an important preventive measure to implement.
With regard to involuntary forced feeding, APA and NCCMH/NICE are in agreement that the legal basis and ramifications for doing so must be clear. NCCMH/NICE notes that it is a highly specialized procedure, only to be used as a last resort intervention in the treatment of anorexia nervosa. APA states that the clinical circumstances, family opinion, and relevant legal and ethical dimensions of the patient's treatment must be carefully considered.
APA and NCCMH/NICE agree that appropriate goals of psychological treatment for anorexia nervosa include helping patients to cooperate with their nutritional and physical rehabilitation (including weight gain and/or maintenance), to reduce eating disorder-related behaviors, and to promote psychological recovery.
During the weight gain process, APA recommends individual psychotherapeutic management that is psychodynamically informed, noting that formal psychotherapy may be ineffective. Therapies suggested by NCCMH/NICE include CAT, CBT, IPT, focal psychodynamic therapy, and family interventions focused explicitly on eating disorders. Both groups provide recommendations regarding psychological interventions for inpatient settings, with APA noting that most inpatient-based programs incorporate emotional nurturance and a combination of reinforcers that link exercise, bed rest, and privileges to target weights, desired behaviors, feedback concerning changes in weight, and other observable parameters. NCCMH/NICE recommends a treatment regimen which focuses both on eating behavior and attitudes to weight and shape, as well as to wider psychosocial issues with the expectation of weight gain, but cautions against rigid inpatient behavior modification programs.
APA cites CBT and interpersonal and/or psychodynamically oriented individual or group psychotherapy as appropriate treatments to prevent relapse after weight restoration, adding that overlap between therapies is common. NCCMH/NICE more generally notes that following inpatient weight restoration, people with anorexia nervosa should be offered outpatient psychological treatment lasting at least 12 months that focuses both on eating behavior and attitudes to weight and shape and on wider psychosocial issues, with regular monitoring of both physical and psychological risk.
APA and NCCMH/NICE further agree that psychosocial interventions for bulimia nervosa should be selected based on factors such as patient age, cognitive and psychological development, and family situation. All three groups are in agreement that CBT should be offered as the first-line psychosocial intervention. For patients who do not respond initially to CBT, APA and NCCMH/NICE agree that alternative psychological therapies should be considered, or a combination of therapies should be used. FMSD notes that CBT and medication have been successful. APA and NCCMH/NICE also both cite self-help programs as possible treatment options for bulimia nervosa. Both groups also provide recommendations regarding appropriate psychological treatments for binge eating disorder.
All three guidelines stress the efficacy and importance of family therapy and family involvement in the psychological treatment of children and adolescents at all stages of treatment and/or recovery for both anorexia and bulimia nervosa.
With regard to anorexia nervosa, there is general agreement among the guidelines that antidepressants or other psychopharmaceuticals are only indicated for treating comorbid psychiatric conditions, such as depression. In such cases, APA notes that SSRIs in combination with psychotherapy may be effective for both weight restoration and relapse prevention. FMSD states that a combination of antidepressants and psychotherapy is more effective than psychotherapy alone, but that psychotherapy may be more acceptable to patients.
For the treatment of bulimia nervosa, all three groups agree that the SSRI fluoxetine is the drug of first choice in terms of acceptability, tolerability, and reduction of symptoms. Both APA and NCCMH/NICE cite SSRIs as an appropriate treatment option for binge eating disorder and address the potential benefits and risks.
There is general agreement that special attention must be paid to the side effects and warnings associated with all prescribed medications, with APA and NCCMH/NICE agreeing that careful cardiac monitoring is necessary when drugs that prolong the QTc interval are prescribed.
There are no significant areas of differences between the guidelines.
This Synthesis was prepared by ECRI on January 17, 2008. The information was verified by AAP on January 30, 2008, and by APA and FMSD on February 8, 2008. This Synthesis was revised in October 2008 to remove AAP recommendations.
Internet citation: National Guideline Clearinghouse (NGC). Guideline synthesis: Management of Eating Disorders. In: National Guideline Clearinghouse (NGC) [website]. Rockville (MD): 2008 Feb (revised 2008 Nov). [cited YYYY Mon DD]. Available: http://www.guideline.gov.